Value Plan: XYZ Insurance Company
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.[yourcompany].com or by calling 1-800-XXX-XXXX.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
Preferred:
$1500 person / $3,000 family
Non-Preferred:
$3000 person / $6,000 family
Doesn’t apply to preventive
care, Preferred Provider.
You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your policy or plan document to see when the deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
Yes. Dental Coverage - $50
You must pay all of the costs for these services up to the specific deductible amount
individual / $100. There are no before this plan begins to pay for these services.
other specific deductibles.
Is there an out–of–
pocket limit on my
expenses?
Yes. For Preferred Providers
$5,250 person
$10,500 family
For Non-Preferred Providers
$10,500 person
$21,000 family
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health
care expenses.
What is not included in
the out–of–pocket
limit?
Premiums, copayments,
balance-billed charges, and
health care this plan doesn’t
cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall
annual limit on what
the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a
network of providers?
Yes. See
www.[xyzinsurance].com or
call 1-888-XXX-XXXX for a
list of participating providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
1 of 8
Value Plan: XYZ Insurance Company
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
Do I need a referral to
see a specialist?
No. You don’t need a referral to
You can see the specialist you choose without permission from this plan.
see a specialist.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan
document for additional information about excluded services.
OMB Control Numbers [insert
numbers]
Corrected on [date]
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use preferred providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
Services You May Need
Primary care visit to treat an injury or illness
If you visit a health
care provider’s office
or clinic
Specialist visit
Other practitioner office visit
Preventive care/screening/immunization
Your Cost If
You Use a
Preferred
Provider
20% after
deductible
20% after
deductible
20% after
deductible
No charge
Your Cost If
You Use a
Non-Preferred
Provider
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
Limitations & Exceptions
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Mammogram limited to once annually
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Value Plan: XYZ Insurance Company
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Diagnostic test (x-ray, blood work)
If you have a test
Imaging (CT/PET scans, MRIs)
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.[xyzinsurance].com
If you have
outpatient surgery
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs
Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees
Emergency room services
If you need
immediate medical
attention
Emergency medical transportation
Urgent care
If you have a
hospital stay
Facility fee (e.g., hospital room)
Physician/surgeon fee
Your Cost If
You Use a
Preferred
Provider
Coverage Period: 01/01/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
Your Cost If
You Use a
Non-Preferred
Provider
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
Limitations & Exceptions
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Covers up to a 30-day supply
(retail prescription)
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3 of 8
Value Plan: XYZ Insurance Company
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Mental/Behavioral health outpatient services
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health inpatient services
Substance abuse disorder outpatient services
Substance abuse disorder inpatient services
Prenatal and postnatal care
If you are pregnant
Delivery and all inpatient services
Home health care
Rehabilitation services
If you need help
recovering or have
other special health
needs
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
Eye exam
If your child needs
dental or eye care
Glasses
Dental check-up
Your Cost If
You Use a
Preferred
Provider
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
20% after
deductible
No Charge
No Charge up to
$175 / Member
No Charge
Coverage Period: 01/01/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
Your Cost If
You Use a
Non-Preferred
Provider
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
No Charge up to
$175 / Member
No Charge
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
Limitations & Exceptions
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–––––––––––none–––––––––––
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–––––––––––none–––––––––––
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Limited to one exam every 2 yrs
Limited to one pair of glasses every 2
years
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4 of 8
Value Plan: XYZ Insurance Company
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
•
Bariatric surgery
•
Long-term care
•
Private-duty nursing
•
Hearing aids
•
Non-emergency care when traveling outside
the U.S.
•
Routine foot care
•
Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
•
•
Acupuncture (if performed as a form of
anesthesia in connection with a covered
surgical procedure)
Chiropractic care
•
Cosmetic surgery
•
Dental care (Adult)
•
Infertility treatment
•
Most coverage provided outside the United
States. See www.[xyzinsurance].com
•
Routine eye care (Adult)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep
health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium
you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your state insurance department,
the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health
and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
5 of 8
Value Plan: XYZ Insurance Company
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
Your Grievance and Appeals Rights:
•
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: Your Company’s Helpline @ 800-XXX-XXXX or the Department of Labor’s
Employee Benefits Security Administration @ 866-444-3272.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
6 of 8
Value Plan: XYZ Insurance Company
Coverage Period: 1/1/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
Coverage Examples
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
Amount owed to providers: $7,540
Plan pays $4,800
Patient pays $2,700
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$1500
$0
$1200
$0
$2,700
Note: These numbers assume the patient has
given notice of her pregnancy to the plan. If
you are pregnant and have not given notice of
your pregnancy, your costs may be higher.
For more information, please contact: Your
Company’s Helpline @ 800-XXX-XXXX.
Amount owed to providers: $5,400
Plan pays $3,100
Patient pays $2,300
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$1500
$0
$800
$0
$2,300
Note: These numbers assume the patient is
participating in our diabetes wellness
program. If you have diabetes and do not
participate in the wellness program, your
costs may be higher. For more information
about the diabetes wellness program, please
contact: Your Company’s Helpline @
800-XXX-XXXX.
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
7 of 8
Value Plan: XYZ Insurance Company
Coverage Examples
Coverage Period: 1/1/2013 – 12/31/2013
Coverage for: Individual + Family | Plan Type: POS
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
•
•
•
•
•
•
•
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-800-XXX-XXXX or visit us at www.[yourcompany].com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-XXX-XXX-XXXX to request a copy.
8 of 8